AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training

1. AHRQ’s Safety Program forNursing Homes: On-Time Falls PreventionFacilitator Training Introduction to Falls Reports

2. Falls PreventionElectronic Reports • Electronic Reports • Falls High-Risk Report • Summary of Fall Risk Factors (by Unit or Facility) • Contextual Factors Report (by Unit or Facility) • Postfall Assessment Report (by Resident) On-Time Falls Prevention

3. Teaching the Falls Prevention Electronic Reports • The teaching sessions for each report should include the following content: • Purpose of the report • Content of the report • Calculation details • Quizzes and exercises On-Time Falls Prevention

4. Postfall Assessment Data Elements • Required data elements include: • The date and time of the fall. • The name of the person who witnessed the fall, OR the name of the person who found the resident (if the fall was not witnessed). • The location where the resident fell. • The position the resident was found in. • The activity the person was engaged in when he or shefell, if the fall was witnessed. On-Time Falls Prevention

5. Postfall Assessment Data Elements • Additional data elements include: • Suspected cause of the fall. • Description of any injury and treatment. • Physician notification and examination. • Family notification. • Physical therapy evaluation, if indicated. On-Time Falls Prevention

6. Postfall Assessment Data Elements • These data are typically collected and documented in a facility’s EMR by staff immediately after a resident’s fall. • Facilities should work with their EMR vendors to determine how and when these data are currently documented. On-Time Falls Prevention

7. Falls High-Risk Report • Provides a weekly snapshot summary of facility residents at highest risk of falling • Enables staff to be more proactive, consistent, and accurate when identifying residents at risk • Helps clinicians see changes in resident status earlier, and identify residents at risk before they fall On-Time Falls Prevention

8. Falls High-Risk Report • How many residents triggered for highest risk of falling? • What are the most common risk factors? • Which acute change was seen most often? Least often? • How many residents at highest risk are cognitively impaired? Have no cognitive impairment? • How many residents at highest risk had a change in status during the report week? On-Time Falls Prevention

9. Falls High-Risk Report:High-Risk Criteria • Risk criteria identified based on: • A review of the literature • Fall elements and scoring from existing instruments • Input from an advisory panel of leading experts and nursing home users On-Time Falls Prevention

10. Falls High-Risk Report:High-Risk Criteria • Risk determined based on a combination of the following elements: • Presence of existing conditions considered high risk • A change of condition of one or more risk elements • New contributing risk factors On-Time Falls Prevention

11. Rules for Determining High Risk • Rule #1: High Risk Based on an Existing Condition Within 90 Days: • Residents will be flagged as “high risk” using this criterion if they have at least 3 of the 4 following conditions: • Severe cognitive impairment or unsafe behaviors • Gait and balance instability • A history of falls within the last 180 days • Use of psychoactive medications On-Time Falls Prevention

12. Rules for Determining High Risk Rule #2: High Risk Based on a Change of Status Within 7 Days: Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition andone of the following changes in status: Orthostatic hypotension/ dehydration Vertigo/dizziness Syncope fainting Hypoglycemia Possible infection New seizure activity New admission • Acute mental status change • New unsafe behaviors • New gait/balance problem or mobility device • New fall • New medication or dosage change On-Time Falls Prevention

13. Rules for Determining High Risk • Rule #3: High Risk Based on New Contributing Risk Factor Within 7 Days: • Residents will be flagged as “high risk” using this criterion if they have at least one high-risk existing condition and one of the following new contributing factors: • New or uncontrolled pain • New or increased urinary incontinence • Increased independence in mobility • Room change On-Time Falls Prevention

14. ADL Changes and Additional Info • Supplementary information about activities of daily living • Included in the Falls High-Risk Report but not used in calculations of high risk On-Time Falls Prevention

15. ADL Changes and Additional Info • Includes changes in last 7 days: • Decline in bed mobility, transfer, or toileting • Symptoms of depression • Low body mass index • Significant weight change • An active physician’s order for vitamin D • Osteoporosis • Diabetes • Visual impairment On-Time Falls Prevention

16. Sample Falls High-Risk Report Unit: Date: ___/___/___ * If current score higher than prior score, then display score and asterisk (*). On-Time Falls Prevention

17. Falls High-Risk Report Calculation Details • Displays the following data for Existing Conditions: • Mental: Unsafe Behaviors • Mental: Cognitive Impairment • Gait and Balance Instability • Fall Within 30 Days • Fall Within 31-180 Days • Psychoactive Medications • Other High-Risk Medications On-Time Falls Prevention

18. Falls High-Risk Report Calculation Details • Displays the following Change in Condition data: • Acute Mental Status Change • Behavior: New Unsafe • New Gait/Balance or Device Order • New Fall • Medication: New Medication or Dose Change • Orthostatic Hypotension/Dehydration • Vertigo/Dizziness • Syncope/Fainting • Hypoglycemia • Possible Infection • New Seizure Activity • New Admission On-Time Falls Prevention

19. Falls High-Risk Report Calculation Details • Displays the following New Contributing Risk Factors: • Pain: New or Uncontrolled Chronic • Urinary Incontinence • Mobility: More Independent • Room Change On-Time Falls Prevention

20. Falls High-Risk Report Calculation Details • Displays the following contributing ADL Decline and Other Clinical Information: • Bed Mobility Decline • Transfer Decline • Toileting Decline • Depression Score (PHQ-9 or PHQ-90V) Increase • Monthly BMI <22 kg/m2 • Significant Weight Change • Vitamin D Order • Osteoporosis • Diabetes • Visual Impairment On-Time Falls Prevention

21. Check Your Understanding:Falls High-Risk Report Quiz • A resident who wanders according to his most recent MDS assessment has met which of the following high-risk existing conditions (HRECs)? • HREC 1: Mental Instability • HREC 2: Gait and Balance Instability • HREC 3: Fall History • HREC 4: High-Risk Medication Profile On-Time Falls Prevention

22. Check Your Understanding:Falls High-Risk Report Quiz • High-risk changes of condition data elements are captured from multiple data sources within the facility’s EMR and represent changes in a resident’s clinical condition within how many days of the report date? • 5 days • 7 days • 10 days • 14 days On-Time Falls Prevention

23. Check Your Understanding:Falls High-Risk Report Quiz • Which of the following sources are used to determine changes in levels of urinary incontinence and activities of daily living? • Nurses’ notes • MDS assessments • Nursing assistant documentation • Therapy notes and evaluations On-Time Falls Prevention

24. Summary of Falls Risk Factors Report • Provides information regarding the number and percentage of falls that have occurred for residents with each risk factor included in the Falls High-Risk Report • Note that a fall may be associated with multiple risk factors. • Can be used by nursing and QI teams to identify trends, support root cause analysis, and target areas for improvement On-Time Falls Prevention

25. Summary of Falls Risk Factors Report • Report displays falls information at the unit or facility level. • Report can be used to monitor overall prevalence and trends of risk factors associated with falls on a specific unit or facilitywide. • Data may be trended for 1 month or 3 months. On-Time Falls Prevention

26. Summary of Falls Risk Factors Report Calculation Details • Displays the following data: • High-Risk Existing Condition • High-Risk Existing Change of Condition Within 7 Days of Fall • New Contributing Risk Factor Within 7 Days of Fall • Additional Information • Injury • Falls With Major Injury • Falls With Minor Injury On-Time Falls Prevention

27. Sample Summary of Falls Risk Factors Report On-Time Quarterly Summary of Falls Risk Factors by Unit Nursing Unit: Date: ___/___/___ On-Time Falls Prevention

28. Check Your Understanding: Summary of Falls Risk Factors Report Quiz • Each resident fall will only be linked to one risk factor on the Summary of Falls Risk Factors Report. • True • False On-Time Falls Prevention

29. Check Your Understanding: Summary of Falls Risk Factors Report Quiz • In order for a high-risk change of condition to appear on the Summary of Falls Risk Factors Reports, it must have been noted within how many days of the fall? • 14 days • 5 days • 7 days • 10 days On-Time Falls Prevention

30. Check Your Understanding: Summary of Falls Risk Factors Report Quiz • A resident’s postfall assessment documents a hematoma on his head, a dislocated hip, and a laceration on his thigh. Which of the following best represents how these injuries will appear on the Summary of Falls Risk Factors Report? • Fall with major injury=1 and fall with minor injury=0 • Fall with major injury=2 and fall with minor injury=1 • Fall with major injury=1 and fall with minor injury=2 • Fall with major injury=2 and fall with minor injury=0 On-Time Falls Prevention

31. Contextual Factors Report • Displays facility trends by contextual factor • Enables comparison of trends across nursing units and aids understanding of the cause of variance • Improves the timeliness of root cause analysis and audit process On-Time Falls Prevention

32. Contextual Factors Report • Displays information on day of the week, shift, time of day, and location of fall and if the resident had a room change in last 30 days • Uses information collected during resident postfall assessments • Can be generated for a single unit or for the facility as a whole • Can show data trended for 1 month or 3 months On-Time Falls Prevention

33. Sample Contextual Factors Report Monthly Contextual Factors Report Date: ___/___/___ Note: Percentages may not add to 100 due to rounding. On-Time Falls Prevention

34. Contextual Factors Report Calculation Details • Displays the following data: • Day of Week: Monday–Sunday • Shift: Days, Evenings, Nights • Time of Day • Location • Other: Room Change Within 30 Days of Fall Date • Total Residents Who Fell • Total Residents With >1 Fall • Total Falls On-Time Falls Prevention

35. Sample Contextual Factors Graph Time of Day Shift Day of Week On-Time Falls Prevention

36. Check Your Understanding: Contextual Factors Report Quiz • Which of the following is the source for the day of the week, shift, and time of a fall on the Contextual Factors Report? • Nurses’ notes • Resident Care Plan • Postfall Assessment • Physician Progress Notes On-Time Falls Prevention

37. Check Your Understanding: Contextual Factors Report Quiz • For the Contextual Factors Report to display the shift on which the fall occurred, the Postfall Assessment must include a field labeled “shift.” • True • False On-Time Falls Prevention

38. Check Your Understanding: Contextual Factors Report Quiz • Within how many days of a resident fall must a room change occur in order for it to be associated with a fall in the quarterly Contextual Factors Report? • 7 • 14 • 30 • 90 On-Time Falls Prevention

39. Postfall Assessment Summary Report • Displays a single resident’s fall details as recorded on the postfall assessment • Can display trended data for up to six postfall assessments • Can display more columns if the facility’s EMR vendor has the ability to display additional data On-Time Falls Prevention

40. Sample Postfall Assessment Summary Report Resident Name: On-Time Falls Prevention

41. Sample Postfall Assessment Summary Report: Injury Section On-Time Falls Prevention

42. Sample Postfall Assessment Summary Report: Notifications Section On-Time Falls Prevention

43. Postfall Assessment Summary Report • Displays the following data: • Fall Date • Fall Time • Fall Witness • Witness Type • Witness Name • Found By • Fall Location • Position When Found • Activity at Time of Fall • Injury Assessment Notes • Bleeding • Suspected Cause of Fall • Fall Comments • Fall Injury • Injury Type Major • Injury Type Minor • Injury Site • ROM Upper • ROM Lower • Loss of Consciousness • Neurological Status On-Time Falls Prevention

44. PostfallAssessment Summary Report • Displays the following data: • Treatment Location • Physician Notified • Physician Name • Physician Notification Date • Physician Notification Time • Family Notification • Family Relationship • Family Notification Date • Family Notification Time • Physician Exam • PT Consult On-Time Falls Prevention

45. Check Your Understanding: Postfall Assessment Summary Report Quiz • Up to how many falls are displayed on the Postfall Assessment Summary Report? • 3 • 4 • 5 • 6 On-Time Falls Prevention

46. Check Your Understanding: Postfall Assessment Summary Report Quiz • Up to three residents can be displayed in a single Postfall Assessment Summary Report. • True • False On-Time Falls Prevention

47. Check Your Understanding: Postfall Assessment Summary Report Quiz • Suspected Cause of Fall will display one causative factor for each fall. • True • False On-Time Falls Prevention